Massey, Wood and West, Inc.

Fueling Richmond with prompt dependable service since 1923.
                                           804-355-1721

New Account Form
New Account Application

To establish a new account, fill out the form below or call the Credit Department at 804-355-1721.

Type of Account Requested:

Date:

First Name:

Last Name:

Social Security Number Required for 30 day accounts:

Home Address:

Home Phone Number:

Length of time there:

Own or Rent:

Employer:

Employer Address:

Employer Phone Number:

Nearest Relative (not living with you):

 

 

Nearest Relative (not living with you) Address:

Nearest Relative (not living with you) Phone Number:

If joint account check here and fill out joint account info. 

Joint Account

Co-Applicant First Name:

Co-Applicant Last Name:

Co-Applicant Social Security Number:

Co-Applicant Employer:

Co-Applicant Employer Address:

Co-Applicant Employer Phone Number:

Bank Information Checking Account:

Bank Information Savings Account:

 

 

 

Product Information

Previous Supplier:

Product Type:

Tank Size:

Above Ground or Underground Tank:

Automatic Delivery or Will Call:

Credit Agreement:

Contact Us
 Massey@masseywoodandwest.com
800-552-2133
804-355-1721